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Clinical Nursing Skills

13.4 Blood Transfusions

Clinical Nursing Skills13.4 Blood Transfusions

Learning Objectives

By the end of this section, you will be able to:

  • Describe steps for administering blood and blood products
  • Understand procedures for initiation and transfusion of blood
  • Recall different blood transfusion reactions

Blood transfusions are potentially life-saving procedures that replace deficits in blood volume or blood cells with blood donated by the patient (autologous donation) or another individual (Association for the Advancement of Blood and Biotherapies [AABB], 2018). A variety of clinical conditions may require administration of whole blood and blood products, individual components of blood, such as red blood cells, platelets, plasma, cryoprecipitated antihemophilic factor (cryo), white blood cells, and granulocytes. They may be needed to increase circulating blood volume after surgery, trauma, or hemorrhage. Other times, blood and blood products may be necessary to increase the number of red blood cells (RBCs) to maintain hemoglobin levels for those with severe anemia or to provide cellular replacement therapy. It is critical for the nurse to learn the proper method of administering blood transfusions and be able to identify potential adverse reactions.

Administering Blood and Blood Products

When administering blood and blood products, the nurse should always verify the provider’s order, including the type of product, amount, date, time, rate, duration of infusion, and specific transfusion instructions, with another qualified provider (AABB, 2018; The Joint Commission, 2021). After verifying the order, the nurse should identify if the patient needs pre- or post-transfusion medications, assess related laboratory values, and understand why the transfusion is indicated for the patient.

The nurse may then explain the procedure to the patient and answer any questions they have. Ask the patient if they have ever received a blood transfusion in the past, and if so, how they tolerated the procedure and if they were premedicated prior to the procedure. Premedicating the patient prior to a blood transfusion may minimize the risk of allergic reactions to blood products. Indications for premedication may include patients with a history of an allergic reaction to blood transfusions, multiple transfusions, chronic illnesses, anxiety, febrile reactions, or autoimmune disorders.

Confirm blood type and crossmatch and await notification from the blood bank that the blood or blood products are ready to be administered. Just before obtaining the blood products, collect baseline vital signs, and notify the provider if temperature is greater than 100°F (37.8°C).

Cultural Context

Blood and Blood Products for Jehovah’s Witnesses

Jehovah’s Witnesses may refuse blood or blood product transfusions due to their religious beliefs. These individuals may refuse whole blood or primary blood components but may accept blood derivatives, such as albumin, clotting factor, and immunoglobulins. It is important to assess patient religious beliefs that may interfere with treatment by blood transfusions, but never automatically assume they will refuse the treatment. Instead, educate the patient as to why the blood transfusion is needed, ask the patient about their individual preferences, and respect their wishes if they refuse the blood transfusion. If the patient does refuse the treatment, document the refusal, and notify the provider.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Preparing for a Blood or Blood Product Transfusion

See the competency checklist for Preparing for a Blood or Blood Product Transfusion. You can find the checklists on the Student resources tab of your book page on openstax.org.

Blood Typing and Crossmatching

Blood typing and crossmatching ensure compatibility of the donor’s blood with the recipient’s blood. The blood typing results identify the blood type and Rh factor. And crossmatching is used to check for harmful interactions between the donor’s and recipient’s blood. Blood typing and crossmatching are essential to caring for patient safety when a blood transfusion is required.

Blood Types

Blood type depends on the antigens found in the RBCs. There are four main types of blood: A, B, AB, and O. Type A blood contains type-A antigens. Type B blood contains type-B antigens. Type AB blood contains type-A and type-B antigens. Type O blood has no antigens, making it well suited for donation.

Rh Factor

Rh factor is determined by whether a certain protein, rhesus factor, is present on the RBCs. Blood may be classified as either Rh positive (+) or Rh negative (−). Rh+ blood contains the Rh protein on the RBCs, whereas Rh− blood lacks the Rh protein. Rh+ is the most common blood type, but Rh− blood does not indicate illness or affect one’s health.

The Rh factor is one of the key factors that determine the compatibility of blood for transfusion. For a blood transfusion to be safe and successful, the recipient’s Rh type must match the donor’s Rh type. For example, a patient who is Rh-negative should receive blood from an Rh-negative donor to avoid potential transfusion reactions. Mismatched Rh factors during a blood transfusion can lead to adverse reactions, including hemolysis (destruction of RBCs), fever, jaundice, and more serious complications. Therefore, ensuring compatibility in terms of the Rh factor is crucial to prevent these reactions.

Blood Donors

When receiving a blood transfusion, it is important that the blood of the donor is compatible with the blood of the recipient. Antibodies may trigger immune reactions against blood that is incompatible. Persons with type A blood should only receive types A or O blood. Persons with type B blood should only receive types B or O blood. Persons with type AB blood are universal recipients and can receive types A, B, AB, or O blood. While persons with type O blood are universal donors and can give to anyone regardless of recipient’s blood type, persons with type O blood may only receive type O blood. Type O blood is often used in emergent situations when blood typing cannot be performed.

In addition to the blood type, the Rh factor plays a critical role. Persons with Rh+ blood may receive both Rh+ and Rh− blood. Those with Rh− blood, however, can only receive Rh− blood. For the transfusion to be considered safe, both the blood type and Rh factor must be compatible (Table 13.2).

Blood Type Can Donate To Can Receive From
A+ A+, AB+ A+, A−, O+, O−
O+ O+, A+, B+, AB+ O+, O−
B+ B+, AB+ B+, B−, O+, O−
AB+ AB+ All types
A− A+, A−, AB+, AB− A−, O−
O− All types O−
B− B+, B−, AB+, AB− B−, O−
AB− AB+, AB− AB−, A−, B−, O−
Table 13.2 Blood Compatibility by Type and Rh Factor

Blood Components

Blood may be administered as whole blood or as individual blood components. Individual blood components can treat particular conditions and allow multiple people to benefit from one pint of whole blood. Blood components include RBCs, platelets, plasma, cryoprecipitated antihemophilic factor (cryo), white blood cells, and granulocytes. For example, a patient with low hemoglobin due to anemia can receive a red blood cell transfusion that contains just the RBCs. A cancer patient receiving chemotherapy can receive a platelet transfusion to correct a low platelet count. A person with clotting factor deficiencies can receive a transfusion of fresh frozen plasma to treat their specific clotting disorder.

A red blood cell, also known as an erythrocyte, is the most administered blood component. They carry oxygen from the lungs throughout the body and take carbon dioxide back to the lungs. As the name suggests, RBCs are red in color (Figure 13.23). Commonly referred to as packed red blood cells, they increase hemoglobin and iron levels and improve oxygen levels within the body. They are most frequently administered to patients experiencing anemia.

A photograph shows bags of packed red blood cells.
Figure 13.23 Packed red blood cells are labeled with unique numbers and packaged for transfusion. (credit: “160113-F-YM354-011” by Tech Sgt. James Hodman/U.S. Air Force, Public Domain)

A platelet, also known as a thrombocyte, is a small, colorless cell fragment that sticks to the lining of a blood vessel to stop bleeding. Platelets are often given to patients experiencing leukemia, blood disorders, or other types of cancer. Some patients with cancer require platelet transfusions as a side effect of chemotherapy, while other patients may have a type of cancer that itself stops the body from creating platelets.

The liquid portion of the blood that carries the red and white blood cells throughout the body is termed plasma. It helps to maintain blood pressure and volume, carries electrolytes to muscles, assists in maintaining pH balance, and supplies proteins for clotting and immunity. Plasma is yellow in color and must be kept frozen to preserve the clotting factor (Figure 13.24). Plasma transfusions are often required for those experiencing liver failure, severe infections, shock, bleeding disorders, or serious burns. During the COVID-19 pandemic, some patients with specific symptoms were treated with convalescent plasma therapy to possibly hasten their recovery.

A photograph shows a bag of plasma with label.
Figure 13.24 Plasma is labeled and packaged for transfusion. (credit: “160113-F-YM354-006” by Tech. Sgt. James Hodgman/U.S. Air Force, Public Domain)

A portion of plasma that is rich in clotting factors is termed cryoprecipitated antihemophilic factor (cryo). It helps reduce blood loss by slowing or stopping bleeding. It is white in color and must be kept frozen to preserve the clotting factor. Cryo is used for clotting disorders, such as hemophilia and von Willebrand disease.

The white blood cells, also known as leukocytes, help the body fight against disease. They destroy bacteria and create antibodies against bacteria, viruses, and diseases. While your own white blood cells help you to remain healthy, foreign white blood cells may suppress the immune system or be toxic when transfused in other persons. Some patients have very few white blood cells because of severe illness. A transfusion of white blood cells would help their body fight infection, in the same way that more soldiers are brought in to fight a battle.

The granulocytes are a particular type of white blood cell that protect against infection by destroying invading bacteria and viruses. They may be administered to treat infections that are not responsive to antibiotics.

Starting a Blood Transfusion

Before a blood transfusion, there are a number of steps nurses must take. Nurses should ensure completion of blood type determination and crossmatch, obtain baseline vital signs, and collect necessary supplies at the bedside, such as blood tubing and normal saline. The nurse must also explain the procedure to the patient and inform the patient to immediately report symptoms of a possible blood transfusion reaction, such as sweating, chills, chest pain, shortness of breath, headache, back pain, nausea, vomiting, or itching. Then it is time to obtain blood from the blood bank. As a general rule, only retrieve one package of blood or blood products from the blood bank at a time. A transfusion must be started within thirty minutes and must be completed within four hours of obtaining the blood. At the blood bank and once on the unit, the nurse must verify the identity of the patient, transfusion order, transfusion consent, blood type, and compatibility before beginning the transfusion.

Real RN Stories

Preparation Is Important before Administering Blood Products

Nurse: Jocelyn, RN
Clinical setting: Inpatient orthopedic unit
Years in practice: 13
Facility location: South Carolina

As a nurse for over thirteen years, I have administered blood on numerous occasions. Administering blood requires careful planning to ensure that the process goes smoothly. Over the years, I have learned that up-front preparation can save you a lot of time and effort in the end. For example, prior to obtaining the blood, always check to make sure that the patient’s IV is properly working, that you have a vital sign machine in the patient’s room, and that you have the necessary supplies, such as blood tubing and normal saline.

I encountered a situation in which the patient’s IV was saline locked; I went to hang the blood and found the IV was occluded. After two attempts to restart the IV, the IV team had to be called to restart the IV. Realizing time was ticking, I had to return the blood to the blood bank until the IV could be restarted. Another time, I was attempting to find a vital sign machine, but they were all occupied by the nursing aides. After searching the unit for over ten minutes, I finally located a vital sign machine. Then I had to find another nurse to verify the blood, which took another five to ten minutes. That left a very short window of time for the blood products to be initiated within the given twenty- to thirty-minute window. Other times, I have had the blood in hand and the second nurse waiting for me in the room only to find the blood tubing bin empty in the supply room. Thankfully, I was able to go to another department and borrow blood tubing, but it would have been more efficient to have gathered the blood tubing prior to obtaining the blood. These lessons have taught me to always plan ahead when administering blood so that everything is in the patient’s room and ready to go once the blood has been gathered from the blood bank.

Start the infusion slowly for the first fifteen minutes, rates determined per facility policy. Remain at the patient’s bedside for the first fifteen minutes and monitor for adverse reactions (INS, 2024). After fifteen minutes, retake and document vital signs. If vital signs remain stable and the patient does not display symptoms of a reaction, increase the rate of the blood according to the agency’s policy. Obtain and document vital signs every hour for the duration of the transfusion. Instruct the patient and family to report any unusual reactions immediately (AABB, 2018). Once the transfusion has ended, clamp the blood tubing above the filter, open the roller clamp for the normal saline, and flush the tubing until no visible blood remains in the IV tubing. Disconnect the blood tubing from the patient’s IV and discard the tubing in an appropriate biohazard container. Obtain and document a final set of vital signs as well as the patient’s post-transfusion status.

Verification Protocols

After retrieving the blood or blood products from the blood bank, two nurses must verify the provider’s order and ensure that the blood product label matches the information found on the patient’s blood bank bracelet (AABB, 2018). One nurse should read the information from one source while the other nurse confirms the same information on the other source. Both nurses should verify the serial number, blood component, blood type, Rh factor, and expiration date match. Confirm the identity of the patient as well, by looking at the blood product label and patient’s identification bracelet, the patient’s name, date of birth, and medical record number. Both nurses should document their verification according to the agency’s policy (Figure 13.25). If any discrepancies are noted, do not start the transfusion, and immediately notify the blood bank.

A blank transfusion record is shown.
Figure 13.25 Documenting blood administration may vary between facilities but includes the product infused, volume infused, and any adverse reactions noted during the transfusion. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Blood Tubing

When administering blood and blood products, it is critical to use tubing that is specially marked as blood tubing (Figure 13.26). Blood tubing is a Y-tube with a special micromesh filter that prevents blood clots and particles from accidentally being administered to the patient. Make sure that all roller clamps (two above the filter and one below the filter) are closed prior to proceeding. Using one of the Y-connectors, spike a bag of normal saline, unclamp the roller clamp above the Y-site on the saline tubing, squeeze the filter chamber until the saline covers the filter and fills one-third to one-half of the drip chamber. Open the roller clamp below the drip chamber to prime the saline tubing all the way to the distal end of the tubing, then clamp the roller clamp.

An illustration shows a Y-shaped tubing with filter connected to a patient’s arm.
Figure 13.26 A Y-shaped tubing with filter is used when administering blood and blood products. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Spike the blood with the other Y-tubing by carefully inserting the IV tubing into the port, being careful not to puncture any portion of the blood bag except the port area. Ensure the spike is completely entered into the blood bag. Unclamp the roller clamp on the blood Y-tubing and squeeze the filter chamber until the blood covers the filter. Write the date and time on the blood tubing because blood tubing should be changed at least every four hours to reduce the risk of bacterial growth.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Administering a Blood Transfusion

See the competency checklist for Administering a Blood Transfusion. You can find the checklists on the Student resources tab of your book page on openstax.org.

Transfusion Reactions

When administering blood and blood products, there is always a risk of a transfusion reaction. Reactions may be mild or severe and occur within twenty-four to forty-eight hours post-transfusion. Transfusion reactions are categorized as allergic, febrile, hemolytic transfusion, circulatory overload, or bacterial. While a reaction may occur at any point during the transfusion, most reactions typically occur within the first fifteen to twenty minutes after administration. As such, it is critical that the nurse remain with the patient for at least the first fifteen minutes of the transfusion (or longer if required by the agency’s policy) and monitor vital signs. Monitor altered vital signs, such as increased temperature or respiratory rate, closely.

If you suspect a reaction, immediately stop the transfusion, and notify the provider. If the patient experiences an adverse reaction that may be uncomfortable but generally not life-threatening, considered a mild reaction, such as a fever, itching, rash, or mild discomfort at the infusion site, stop the transfusion and notify the provider. Many times, the provider will treat the symptoms (such as administering acetaminophen for a fever or diphenhydramine for itching) and continue the transfusion with close monitoring of the patient.

Moderate reactions are characterized by more pronounced symptoms that can cause discomfort and concern, such as moderate to severe shortness of breath, significant fever, and pronounced skin reactions. Moderate reactions can result from factors like transfusion-associated circulatory overload, more severe allergic responses, or worsening of mild reactions. In the event of moderate reactions, stop the transfusion, and notify the provider. Management of moderate reactions may involve slowing or stopping the transfusion as well as symptom treatment. Severe reactions are the most serious and life-threatening type of transfusion reaction. They can include severe respiratory distress, shock, renal failure, severe hemolysis (destruction of red blood cells), and cardiovascular collapse. Severe reactions are typically caused by major incompatibilities, such as ABO or Rh mismatches, transfusion of incompatible blood components, bacterial contamination, or acute hemolytic reactions. Severe reactions require immediate discontinuation of the transfusion, aggressive supportive care, and specific treatments tailored to the underlying cause. Management may include administering medications, providing oxygen, and ensuring hemodynamic stability.

In the event a transfusion reaction occurs and the blood is discontinued by the provider, disconnect the blood tubing and start normal saline with new IV tubing to keep the IV line open. If the patient is experiencing shortness of breath, sit the patient upright and start oxygen. Remain with the patient and monitor vital signs every fifteen minutes. Prepare to administer emergency medications, such as antihistamines, fluids, steroids, or vasopressors, depending on the provider’s orders or standing protocols that may be in place. Collect blood and urine samples according to agency policy and provider orders. Check all blood bag labels, forms, orders, and the patient’s identification band to determine whether a clerical discrepancy exists. Keep the blood container, tubing, and transfusion record and send to the blood bank for analysis. Document the symptoms, the time symptoms began, actions taken, as well as the patient’s current condition. Complete an incident report according to the agency’s policy.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Managing a Blood or Blood Product Transfusion Reaction

See the competency checklist for Managing a Blood or Blood Product Transfusion Reaction. You can find the checklists on the Student resources tab of your book page on openstax.org.

Allergic Reaction

An allergic reaction occurs when the immune system reacts to the donor’s antibodies. Common symptoms of an allergic reaction include flushing, hives, rash, pruritus, difficulty breathing, laryngeal edema, wheezing, and possible anaphylaxis. Treatment for allergic reactions may include antihistamines, steroids, and epinephrine.

Patient Conversations

What If Your Patient Experiences a Transfusion Reaction?

Scenario: Provider ordered two units packed red blood cells (PRBCs). The nurse initiated the first unit of PRBCs ten minutes ago.

Patient: Nurse, I don’t feel so good.

Nurse: Mr. Jackson, can you tell me more about how you are feeling?

Patient: I’m itching all over, and I feel like my throat is tight.

Nurse: Mr. Jackson, I’m going to stop the blood transfusion for a moment until we know what is going on. I’m going to take a look at your arms, legs, and back and listen to your heart and lungs.

[Nurse assesses patient.]

Nurse: Mr. Jackson, I noticed you have a rash on your back and arms. I hear wheezing in your lungs, and your heart seems to be beating faster than usual. I think you are having an adverse reaction to the blood products. I’m going to leave the blood turned off and notify your provider.

Patient: Am I going to be okay?

Nurse: You are in good hands, Mr. Jackson. I am right here with you. Let’s check your vital signs so we can monitor your condition. If you begin to feel any worse or feel that you can’t breathe, please let me know.

Febrile Reaction

A febrile reaction occurs when there is hypersensitivity to the donor’s white cells, platelets, or plasma proteins. Febrile reactions cause the body to build antibodies, so this is the most common reaction if the patient has received blood in the past. Common symptoms of a febrile reaction include sudden chills, fever, flushing, headache, and anxiety. Febrile reactions are treated with antipyretics, such as acetaminophen. Depending on the severity of the reaction, the provider may slow, stop, or continue the transfusion. If the transfusion is continued, carefully monitor the patient throughout the transfusion and promptly report any additional or worsening symptoms that may arise.

Hemolytic Transfusion Reaction

A hemolytic transfusion reaction is a severe and potentially life-threatening complication that occurs when a patient receives incompatible blood products. Common symptoms of a hemolytic transfusion reaction include low back pain (first sign), chills, feeling of fullness, tachycardia, flushing, tachypnea, hypotension, bleeding, vascular collapse, and acute renal failure. The patient may also experience a headache, nausea, and hemoglobinuria. Late symptoms may include fever and mild jaundice. Treatment for hemolytic transfusion reactions depends on the severity of the reaction and may include stopping the transfusion, frequently monitoring vital signs, administering IV fluids to maintain blood pressure, providing supplemental oxygen as needed, dialysis, management of bleeding, and supportive measures to manage the patient’s symptoms.

Clinical Judgment Measurement Model

Analyze Cues: Recognizing a Transfusion Reaction

The patient is receiving a unit of PRBCs. The nurse starts the transfusion at a slow rate and remains with the patient for the first fifteen minutes. Five minutes after starting the transfusion, the patient states, “Can I get another pillow to put behind my back? It is hurting a bit, and I can’t seem to get comfortable.” Back pain is a cue that requires a quick-acting response by the nurse; however, there is not enough information to analyze the significance of the cue. The nurse may promptly ask the patient additional questions, such as, “Is your back pain new or was it bothering you earlier today?” “Can you point to where it is hurting?” The nurse may also perform a quick physical assessment to learn more about the cue. Upon assessment, the patient reports that the pain is a new pain occurring in the lower back. Using critical thinking, the nurse quickly considers factors that could potentially cause the symptoms, such as sitting for too long, sleeping on the back wrong, referred kidney pain, or a hemolytic transfusion reaction.

To narrow down a potential cause, the nurse may need to ask additional questions. The nurse asks the patient, “Do you feel any additional symptoms, such as chills, feeling of fullness, nausea, or headache?” The patient reports a slight headache coming on. The nurse obtains a set of vital signs and notes the patient is slightly tachycardic and that their blood pressure has slightly dropped from the baseline vital signs. Upon physical assessment, the patient is flushed and tachypneic. By recognizing and analyzing the quick onset of cues such as lower back pain, headache, tachycardia, blood pressure dropping, flushing, tachypnea, and recent initiation of a blood transfusion, the nurse forms a hypothesis that the patient may be experiencing a hemolytic transfusion reaction, stops the transfusion, and immediately notifies the provider.

Circulatory Overload

A circulatory overload occurs when the blood is administered at a rate faster than the circulatory system can accommodate. Common symptoms of circulatory overload include a rise in venous pressure, dyspnea, crackles or rales, jugular vein distension, cough, and elevated blood pressure. Treatment for circulatory overload includes positioning the patient upright, lowering the feet in a dependent position, diuretics, oxygen, and bronchodilators.

Bacterial Reaction

A bacterial reaction occurs when the blood or blood products are contaminated with bacteria. Common symptoms of a bacterial reaction include rapid onset of chills, vomiting, marked hypotension, and a high fever. Typically, blood cultures and other laboratory tests (complete blood count, coagulation studies, assessment of organ functioning) will be collected to diagnose or confirm this type of reaction. Treatment for bacterial reactions includes antibiotics, increased hydration, steroids, and vasopressors.

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